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HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT. FEE 507•7Z) No Y � t S®. YAiim®U I ri, MA ®2654 COMMONWEALTH Of MASSACHUS�ETTS � O� 7 � Board of Health, , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( - ❑ Complete System ❑ Individual Components Location TSOwner's Name I b Map/Parcel# / d "' Address Lot# 46 Telephone# Installer's NameOW Designer's Name a.on Address l /.D?nnb Address Telephone# - Telephone# a a Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation The under ' ed agrees to install the above described' Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further t notto-place e system ' operatio a Certificate of C / li been issued by the Board of Health. Signed 1�-- t Date ! r Inspections No. / 6 ��717 FEE �t'. (✓C../ Board of Health, O AMA. CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System` The undersi ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: at f . C 7-j4/2 A V e—, u -e has been installed diincaccordance with the provisions of 310 CMR 15.00" (Title 5) and.tdhe ap roved design plans/as-built plans relating to application No. dated b 3"��. Approved Design Flow '7d (gpd) Installer Designer: /� �� ��/ Inspector: Date: The issuance of this permit shall not be construed as a guarantee that a system will function as designed - No. JIF FEE S� Board of Health, ©A , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT PermZsn is e g ed to; Construct( ) e air radde( ) Abandon( )an individual sewage disposal system at ; � G.F=..i �"_ V10 as described in the application for Disposal System Construction Permit No. e dated 4 ,0 `"V Provided: Construction shall be completed //within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date oard of Health /' �( T